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Camp Jeff Waiver Form - 2021

This document contains (1) a waiver form for a cheer and dance camp that collects information about the participant and their parent/guardian, (2) emergency contact information, (3) medical information, and (4) a liability waiver and release of claims signed by the parent/guardian allowing the participant to participate in camp activities.

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Nolan Hahn
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27 views

Camp Jeff Waiver Form - 2021

This document contains (1) a waiver form for a cheer and dance camp that collects information about the participant and their parent/guardian, (2) emergency contact information, (3) medical information, and (4) a liability waiver and release of claims signed by the parent/guardian allowing the participant to participate in camp activities.

Uploaded by

Nolan Hahn
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Cheer and Dance Camps

Waiver Form

PARTICIPANT’S INFORMATION
Participant’s Full Name: _____________________________________________

Age: _______ D.O.B: _______ /_______/___________

School Grade (please circle): 6 7 8 9 10 11 12 School/Organization Name: ________________________

Cell Number: ( ________ ) ________ - ____________ Home Number: ( ________ ) ________ - ____________

Email Address: _____________________________________________

Address:_____________________________________________ ___________________________
Street Address
_________________________________________________________________________
Street Address Line 2
________________________________________ ____________ _____________
City State Zip Code

PARENT/GUARDIAN’S INFORMATION
Parent/Guardian’s Full Name: _____________________________________________

Cell Number: ( ________ ) ________ - ____________ Home Number: ( ________ ) ________ - ____________

Email Address:_____________________________________________

EMERGENCY INFORMATION
Emergency Contact’s Full Name:_____________________________________________

Relationship to athlete: _____________________________________________

Contact Number: ( ________ ) ________ - ____________ Alt. Number: ( ________ ) ________ - ____________

MEDICAL INFORMATION
Please check all that apply:
☐Wears Glasses/Contacts ☐Prescribed inhaler ☐Medication ☐Food allergies ☐Other

Please describe any checked items including instructions/supervision: ____________________________________

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Cheer and Dance Camps
Waiver Form

RELEASE OF LIABILITY FOR PARTICIPANTS - READ CAREFULLY BEFORE SIGNING

IN CONSIDERATION of allowing the below PARTICIPANT to participate in any way at a cheer camp, clinic, or event hosted by NorthShore
Athletics, Inc. dba Camp Jeff the undersigned acknowledges, appreciates, and agrees that:

1. The risk of injury to my child from the activities involved in these programs is significant, including the potential for permanent disability
and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

2. FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING
FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child’s participation; and,

3. I willingly agree to comply with the program’s stated and customary terms and conditions for participation. If I observe any unusual
significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from the participation and
bring such attention of the nearest official immediately; and,

4. I myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE ALL
participants, athletes, NorthShore Athletics, Inc. dba Camp Jeff, Jeffrey Siegal and Justin Boumstein including all officers, employees,
instructors and affiliates, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the
event ("Releasees"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property incident to my
child’s involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to
the fullest extent permitted by law.

5. I, for myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY
AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my involvement or participation in the competition,
EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.

6. I willingly agree to allow NorthShore Athletics, Inc. dba Camp Jeff by means of photography and videography, to publish photographs
and/or video of my child for advertising purposes in all forms of media. I further agree that I consent to the use of said photographs or
video without right to compensation of any type or form.

By signing below, I, a parent or legal guardian of the below named minor participant, hereby indicate that I have read this
document and agree to any and all such terms contained herein.

_____________________________________________ _______ /_______/___________


Printed Name of Participant Participant’s D.O.B.

_____________________________________________
School/Organization Name

_____________________________________________
Printed Name of Parent/Guardian

_____________________________________________ _______ /_______/___________


Parent/Guardian’s Signature Date

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